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“He is 69 years old, on an experimental treatment for metastatic colon cancer, and he has free air,” explained the emergency department physician. It was a Sunday afternoon, and I was the surgeon on call.

The CT scan had been done without intravenous contrast, and the cava was flat, from which I inferred that his renal function was poor. He had liver metastases, but there was still plenty of normal liver, and the metastases alone would not explain this much ascites. There was scattered free air, but too much ascites to be from an acute perforation, and the pleural effusions suggested a more chronic process. There was so much edema of the soft tissues that the interface between fat, muscle, and bowel had been lost. This was not a man who had been holding his own against metastatic cancer; this was a man who had been in the process of dying for some time, and then he perforated.